Last week's Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health did a grave disservice to Americans rightfully upset about the rising tide of drug and alcohol dependency in their communities.
The report failed to address the root causes of an epidemic that has spread to an estimated 27 million people who abuse prescription opioids or use illicit drugs. Nor did it explain why an estimated 66 million people—1 of every 4 adults and adolescents—engage in binge drinking at least once a month.
If drug companies, pain pill mills or overwhelmed primary-care physicians with uncontrolled prescription pads bore any responsibility for the tide of opioids that swept over some areas of the country, you wouldn't know it from this report.
There was a long section on brain chemistry, though. It validates treating addiction like the disease that it is with both counseling and medication.
If John Snow had taken a similar approach to a cholera outbreak in mid-19th century London, he would have counseled drinking beer since local brewers were unaffected (their water was boiled). Instead, he convinced the authorities to remove the handle from the contaminated well, which eventually curbed the epidemic.
I did a little creative Googling last week while attending a conference on Health Systems and Addiction sponsored by ECRI. I turned up Medicare's Part D Opioid Drug Mapping tool, which shows states and counties with opioid prescription rates higher or lower than the national average.
I covered its legend on my computer screen before showing it to one of the presenters, an official from the VA. “Know what this is?” I asked. “An election map?” she answered.
Close. There were some discrepancies. Florida, Wisconsin, Iowa and a few upper Great Plains states that went for Donald Trump had below-average opioid prescription rates. Washington and Oregon, which voted for Hillary Clinton, had above-average rates. But it was almost perfect correlation.
Healthcare officials have turned a blind eye to the social roots of this epidemic largely because they have no tools for addressing them. Joblessness, hopelessness and despair rarely enter into the dialogue.
Instead, the discussion of the “social determinants” of the opioid and alcohol abuse epidemics usually focuses on the behavioral health crisis. We have a very real problem with poorly treated depression, schizophrenia and bipolar disorders, which lead to self-medication, substance abuse and addiction.
Better-run health systems are developing programs to provide food, shelter and counseling and treatment for some of these patients. The hope is that these unreimbursed efforts will prove to be more cost-effective than simply turning stabilized people back onto the streets.
But poorly treated mental health conditions in no way account for the rising number of Americans who needed treatment for their pain, and managed to find willing suppliers within the healthcare system.
That aircraft carrier is finally turning. The American Medical Association, which fought restrictions, has joined the battle against overuse.
Well over half of doctors are now employed by hospital systems, some of which are beginning to monitor prescribing patterns to identify outliers who still haven't gotten the message. Integrated delivery systems like Kaiser Permanente and the VA are deploying teams of counselors, social workers and clinicians to take a holistic approach to treating the pain patient's social, psychic and physical condition, and considering complementary approaches such as massage, biofeedback and acupuncture.
Private insurers and employer-financed plans are increasingly open to supporting these approaches thanks to the bipartisan Mental Health Parity and Addiction Equity Act of 2008. We'll see if the Affordable Care Act's essential benefits for individual plans, which include services to prevent and treat substance use disorders, survive the next Congress.
But the healthcare systems in every community need to do more. Since hospitals are the major employer in almost every community, their leaders are well-positioned to speak out on what's behind the pain epidemic: the economic marginalization of large swaths of working-class America.